Peaceful end-of-life theory
Patricia A. Higgins and Dana M. Hansen
“Standards of care offer a promising approach for the development of middle-range prescriptive theories because of their empirical base in clinical practice and their focus on linkages between interventions and outcomes”
(Ruland & Moore, 1998, p. 169).
Cornelia M. Ruland
1954 to present
Shirley M. Moore
1948 to present
Credentials and background of the theorists
Cornelia M. Ruland
Cornelia M. Ruland received her Ph.D. in nursing in 1998 from Case Western Reserve University in Cleveland, Ohio. She is Director of the Center for Shared Decision Making and Nursing Research at Rikshospitalet University Hospital in Oslo, Norway, and holds an adjunct faculty appointment in the Department of Biomedical Informatics at Columbia University in New York. Ruland has established a research program on improving shared decision making and patient-provider partnerships in health care, and the development, implementation, and evaluation of information systems to support it. She focuses on aspects of and tools for shared decision making in clinically challenging situations: (1) for patients confronted with difficult treatment or screening decisions for which they need help to understand the potential benefits and harms of alternative options and to elicit their values and preferences, and (2) preference-adjusted management of chronic or serious long-term illness over time. As primary investigator on a number of research projects, she has received awards for her work.
The authors wish to express their appreciation to Cornelia Ruland and Shirley Moore for their contributions to the chapter.
Shirley M. Moore
Shirley M. Moore is Associate Dean for Research and Professor, School of Nursing, Case Western Reserve University. She received her diploma in nursing from the Youngstown Hospital Association School of Nursing (1969) and her bachelor’s degree in nursing from Kent State University (1974). She earned a master’s degree in psychiatric and mental health nursing (1990) as well as a Ph.D. in nursing science (1993) at Case Western Reserve University. She has taught nursing theory and nursing science to all levels of nursing students and conducts a program of research and theory development that addresses recovery after cardiac events. Early in her doctoral study, Moore was encouraged by nurse theorists Joyce J. Fitzpatrick, Jean Johnson, and Elizabeth Lenz to not only use theory but to develop it as well. The Rosemary Ellis Theory Conference, held annually for several years at Case Western Reserve University, offered Moore an opportunity to explore theory as a practical tool for practitioners, researchers, and teachers. Influenced by these experiences, Moore has assisted in the development and publication of several theories (Good & Moore, 1996; Huth & Moore, 1998; Ruland & Moore, 1998). Moore considers theory construction an essential skill for doctoral students.
Theoretical sources
The Peaceful End-of-Life Theory is informed by a number of theoretical frameworks (Ruland & Moore, 1998). It is based primarily on Donabedian’s model of structure, process, and outcomes, which in part was developed from general system theory. General system theory is pervasive in other types of nursing theory, from conceptual models to middle-range and micro-range theories—an indicator of its usefulness in explaining the complexity of health care interactions and organizations. In the Peaceful End-of-Life Theory, the structure-setting is the family system (terminally ill patient and all significant others) that is receiving care from professionals on an acute care hospital unit, and process is defined as those actions (nursing interventions) designed to promote the positive outcomes of the following: (1) being free from pain, (2) experiencing comfort, (3) experiencing dignity and respect, (4) being at peace, and (5) experiencing a closeness to significant others and those who care.
A second theoretical underpinning is preference theory (Brandt, 1979), which has been used by philosophers to explain and define quality of life (Sandoe, 1999), a concept that is significant in end-of-life research and practice. In preference theory, the good life is defined as getting what one wants, an approach that seems particularly appropriate in end-of-life care. It can be applied to both sentient persons and incapacitated persons who have previously provided documentation related to end-of-life decision making. Quality of life, therefore, is defined and evaluated as a manifestation of satisfaction through empirical assessment of such outcomes as symptom relief and satisfaction with interpersonal relationships. Incorporating patient preferences into health care decisions is considered appropriate (Ruland & Bakken, 2001; Ruland, Kresevic, & Lorensen, 1997) and necessary for successful processes and outcomes (Ruland & Moore, 2001).
This theory was derived in a doctoral theory course in which Ruland was a student and Moore was faculty. Middle-range theories were just emerging, and there were few good definitions or examples. The class was challenged to think about the future use and development of middle range theory for nursing science and practice. The students discussed knowledge sources from which they could derive middle range theory, such as empirical knowledge, clinical practice knowledge, and synthesized knowledge. Each student was asked to derive a middle range theory from a knowledge source of choice. Ruland had just completed a major project to develop a clinical practice standard for peaceful end of life with a group of cancer nurses in Norway. The standard was synthesized into the theory of peaceful end of life by Ruland and later was refined with Moore’s assistance. This is an example of middle range theory developed by doctoral nursing students as they study knowledge development methods. This theory is also an example of middle range theory development using a standard of practice as a source.
Use of empirical evidence
The Peaceful End-of-Life Theory is based on empirical evidence from direct experience of expert nurses and review of the literature addressing components of the theory. The group of expert practitioners who developed the standard of care for peaceful end of life had at least 5 years of clinical experience caring for terminally ill patients. The standard of care consisted of best practices based on research-derived evidence in the areas of pain management, comfort, nutrition, and relaxation. This prescriptive theory comprises several proposed relational statements for which more empirical evidence is needed. Explicit hypotheses can be derived from these relational statements to be tested their usefulness. The authors of the standard of care and authors of the theory attempted to incorporate clearly described, observable concepts and relationships that expressed the notion of caring.
Major assumptions
Nursing, person, health and environment
As in other middle-range theories the focus of the theory of peaceful end of life does not address each metaparadigm concept. The theory was derived from standards of care written by a team of expert nurses who were addressing a practice problem, therefore, the metaparadigm concepts explicitly addressed were nursing and person. The theory addresses the nursing phenomena of complex, holistic care to support persons’ peaceful end of life.
Two assumptions of Ruland and Moore’s (1998) theory are identified as follows:
Two additional assumptions are implicit:
Theoretical assertions
Six explicit relational statements were identified (Ruland and Moore, 1998) as theoretical assertions for the theory, as follows:
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